COMMENTARY
Investing in Family Planning: Key to Achieving the
Sustainable Development Goals
Ellen Starbird,a Maureen Norton,a Rachel Marcusa
Voluntary family planning brings transformational benefits to women, families, communities, and
countries. Investing in family planning is a development ‘‘best buy’’ that can accelerate
achievement across the 5 Sustainable Development Goal themes of People, Planet, Prosperity, Peace, and
Partnership.
INTRODUCTION
F amily planning encompasses the services, policies,
information, attitudes, practices, and commodities,
including contraceptives, that give women, men,
couples, and adolescents the ability to avoid unintended
pregnancy and choose whether and/or when to have a
child. In this commentary, we outline family planning’s
links to the Sustainable Development Goals (SDGs) and
highlight the transformational benefits that voluntary
family planning brings to women, families, commu-
nities, and countries. We present family planning as a
cross-sectoral intervention that can hasten progress
across the 5 SDG themes of People, Planet, Prosperity,
Peace, and Partnership (Figure). We particularly stress
family planning’s:
 Link to human rights, gender equality, and
empowerment
 Impact on maternal, newborn, child, and adolescent
health
 Role in shaping economic development and envir-
onmental and political futures
Accelerating progress in these areas is critical for
SDG achievement.
We set forth evidence on ways that family planning
can influence SDG achievement. At times, the evidence
is strong; at other times, less so. Our hope is that the
evidence gaps will motivate researchers to address
unanswered questions. Most importantly, we hope that
the evidence presented here leads to action at the
international and country level—to fully support
organized, voluntary family planning in the public
a
U.S. Agency for International Development, Washington, DC, USA.
Correspondence to Rachel Marcus (rmarcus@usaid.gov).
Global Health: Science and Practice 2016 | Volume 4 | Number 2
and private commercial sectors, as well as through civil
society.
This paper outlines the multiple reasons why
investing in family planning is a good decision at every
level. It is aligned with recent studies that find that
investing in family planning is a development ‘‘best
buy.’’1 Accordingly, we hope that the information
presented here will help governments and planners—
including Ministries of Finance, district health teams,
and civil society organizations—to consider family
planning as a fundamental element of any long-term,
socioeconomic development strategy, and key to SDG
achievement.
In 2000, representatives from 189 United Nations
Member States endorsed 8 Millennium Development
Goals (MDGs) to be achieved by 2015, and affirmed
their collective commitment to poverty reduction and
improved quality of life. However, during the next
decade, progress toward MDG 4 (reduce child mortal-
ity), 5 (improve maternal health), and 6 (combat
HIV/AIDs, malaria, and other diseases) was relatively
slow. In fact, MDG 5.B, universal access to reproductive
health, including access to voluntary family planning
(not added until 2007), witnessed the least progress
over the entire 15-year MDG time frame. By 2010,
experts concluded that ‘‘the poorest, least educated
women in sub-Saharan Africa have lost ground, with
adolescents lagging farthest behind.’’2
The international community, however, has made
important strides in recent years. The 2010 ‘‘Global
Strategy for Women’s and Children’s Health’’ has
mobilized new resource commitments, and Family
Planning 2020 (FP2020), the UN Commission on Life-
Saving Commodities, the MDG Health Alliance, and
other groups have revitalized family planning globally.
Civil society organizations are highly engaged at local
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Family Planning and the SDGs
FIGURE. The 5 Sustainable Development Goal Themes of People, Planet, Prosperity, Peace, and Partnership
Investing in family
planning is a
development
‘‘best buy.’’
Despite renewed
momentum,
family planning
investments and
service access fall
short of need in
virtually all low-
resource settings.
Global Health: Science and Practice 2016 | Volume 4 | Number 2
levels to ensure the positive momentum con-
tinues. Despite this renewed momentum, family
planning investments and service access fall short
of need in virtually all low-resource settings.
Below, we present the SDGs using the
organizing principles set forth in the preamble
of the Sustainable Development Goals—People,
Planet, Prosperity, Peace, and Partnership. (Thus,
the SDGs are not always presented in numerical
order in this article.) We then synthesize the
most recent analyses that document family
planning’s importance for the achievement of
the SDGs.
PEOPLE
Family planning affects people in myriad ways.
Most fundamentally, it advances human rights.
Voluntary family planning helps women and
men secure their rights to decide freely, and for
www.ghspjournal.org
themselves, whether, when, and how many
children they want to have—a basic human right.3
Family planning supports the rights of the girl
child to remain unmarried and childless, until she
is physically, psychologically, and economically
ready, and desires to bear children. It supports
the rights of adolescent boys and girls to informa-
tion on how rapid, repeat pregnancies will affect
their future. It strengthens the rights of women
with HIV to decide on future childbearing, free of
coercion. Family planning supports the rights of all
people to accurate, unbiased information on
contraceptive methods that can help them achieve
their reproductive preferences. Yet, in many
countries, despite possessing these inherent rights,
women and girls often bear more children than
they want, or at times when they are not planned.
In 2012, the year for which the most recent
data are available, approximately 85 million
pregnancies, representing 40% of all pregnancies
globally, were unintended.125 This number was
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Family Planning and the SDGs
projected to rise to 92 million by 2015.4 In 2014,
225 million women in the developing world had
an unmet need for a modern contraceptive
method.5 Women with unmet need are defined
as those who want to stop or delay childbearing
but are not using modern contraceptive methods.
SDGs 3.7 and 5.6 support ‘‘universal access to
sexual and reproductive health-care services,
including for family planning’’ and ‘‘universal
access to sexual and reproductive health and
reproductive rights,’’ respectively.6
Beyond human rights, family planning affects
people in other ways, as outlined below.
Goal 1. No Poverty: End Poverty in All Its
Forms Everywhere
Family Planning Helps Reduce Poverty
Over the last 3 decades, extreme poverty has
declined significantly. In 1981, 50% of the
developing world’s population lived on less than
US$1.25 per day. In 2010, this indicator had
dropped to 21%.7 While population’s links to
poverty have been debated over the years, a
consensus is emerging that rapid population
growth can increase the sheer number of poor
people.8
 The latest data show that the share of
Africans who were poor fell from 56% in
1990 to 43% in 2012. Yet, due to population
growth, many more people are poor—about
330 million in 2012, up from about 280 million
in 1990.9
 Equally important, African population growth
is not slowing as quickly as anticipated. In
2015, the UN estimated that Africa had the
highest annual population growth rate among
major geographic areas (2.55%) and projected
that it would remain high in 27 African
countries.10
 Between 2015 and 2050, an estimated
1.3 billion people will be added in Africa.
The populations of Angola, Burundi, Demo-
cratic Republic of the Congo, Malawi, Mali,
Niger, Somalia, Uganda, United Republic of
Tanzania, and Zambia may increase at least
fivefold by 2100.10
The 2015 UN report of population estimates
and projections concludes, ‘‘y population
growth in the poorest countries will make it
harder for those governments to eradicate
poverty and inequality y [and] improve the
provision of basic services.’’10 The challenges
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for poverty reduction strategies and family In 2012,
planning are clear. approximately
At the household level, some studies caution 85 million
against ‘‘the widely held view that large families pregnancies were
are poorer’’ and fail to find links between unintended.
household size and poverty.11 Other studies take
a different approach to examining family plan- SDG 3.7 supports
ning’s contribution to poverty reduction. They universal access to
focus instead on family planning’s role in creating sexual and
human capital. A 2010 study found that the reproductive
family planning program in Colombia reduced health care
women’s completed lifetime fertility by approxi- services, including
mately one-half of a child and explained a family planning.
relatively low 6% to 7% of the fertility decline SDG 5.6 supports
between 1964 and 1993.12 ‘‘Despite its modest universal access to
role in reducing lifetime fertility,’’ the study sexual and
concluded, ‘‘the ability of family planning to
reproductive
fight poverty cannot be easily dismissed.’’ The
rights.
study found that women with access to family
planning as teenagers gained 0.05 more years
of schooling, were 7% more likely to work in
the formal sector, and were 2% less likely to
cohabit with male partners. In addition, young
Colombian women with access to modern contra-
ception ‘‘experienced substantial socio-economic
gains’’ because contraception allowed them to
postpone their first births and determine their life
course. The study concluded that these estimates
may place family planning ‘‘among the most
effective (and cost-effective) interventions to
foster human development.’’12
This work links to other SDGs related to
economic development and poverty reduction,
including Goal 8 (decent work and economic
growth) and Goal 10 (reduced inequalities).
Goal 2. Zero Hunger: End Hunger, Achieve
Food Security and Improved Nutrition, and
Promote Sustainable Agriculture
Family Planning Contributes to Improved Nutrition
Outcomes
As noted in a recent brief on the impacts of family
planning on nutrition, ‘‘undernutrition, which
includes stunting, underweight, wasting, and
vitamin deficiencies, contributes to nearly half
of all childhood deaths. This means that about
3.1 million children under age 5 die each year
from malnutrition-related causes.’’13
The breastfeeding method of family plan-
ning—the Lactational Amenorrhea Method
(LAM), considered a modern method of family
planning14—yields all of the nutritional benefits
of exclusive breastfeeding, and thus can directly
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Family Planning and the SDGs
influence newborn and infant nutritional status.
However, correct use of this method globally is
low at 26% of reported LAM users.15 Scaling up
correct LAM use globally could bring tremendous
nutritional benefits to newborns and infants and
prevent unwanted pregnancy among postpartum
women for 6 months, before transitioning to
another modern method.
Family planning Family planning also helps women time and
helps women time space their pregnancies to ensure healthy nutri-
and space their tional outcomes:
pregnancies to  Spacing pregnancies at least 24 months
ensure healthy apart (the equivalent of 3 years between
nutritional births) is linked to reduction of a key measure
outcomes. of malnutrition—stunting—among children
under 5. Children born after a 2-year interval
or less, compared with a 4-year interval, are
27% more likely to be stunted and 23% more
likely to be underweight.16
 Timing pregnancy to occur after age 18
improves adolescents’ growth and develop-
ment17,18 and reduces the risk of poor out-
comes for their children—stunting, low birth
weight, and preterm birth.19
 Spacing pregnancies helps women replenish
essential nutrients. Studies have found that
‘‘strong evidence’’ exists for women’s folate
depletion at 3 to 12 months postpartum,21 a
deficiency linked to the risk of low birth
weight in the next pregnancy.22,23
 Spacing pregnancies also gives mothers more
time, energy, and resources to breastfeed their
A provider counsels a young woman on birth spacing at a primary
health care center in Kagoro, Nigeria.
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infants. And when pregnancies are planned,
research shows that mothers can breastfeed
for longer periods of time and breastfeeding
practices improve, leading to improved
nutrition.13,24,25,26
Goal 3. Good Health and Well-Being:
Ensure Healthy Lives and Promote Well-
Being at All Ages
Family Planning Saves Lives
Every day, approximately 830 women die from
causes related to pregnancy and childbirth.
Nearly all—99%— of these maternal deaths occur
in low-income countries. More than half of
the deaths occur in sub-Saharan Africa, while
one-third occur in South Asia. In addition, in
2015 5.9 million children died who were under
5 years of age.27
Analyses indicate that, between 2012 and 2020,
family planning could help avert approximately
7 million under-5 deaths and prevent 450,000
maternal deaths in 22 priority countries of the
U.S. Agency for International Development
(USAID).28 A modeling study of 172 countries
estimated that, in 2008 alone, family planning
averted 272,040 maternal deaths—a 44% reduc-
tion compared with the maternal deaths that
would have occurred without contraceptive use.29
It also estimated that satisfying unmet need for
contraception could prevent another 104,000
maternal deaths per year (an additional 30%
reduction).
Demographic high-risk pregnancies—preg-
nancies that occur too early or late in the
mother’s age, are too closely spaced, or are
considered too many (high parity)—are asso-
ciated with higher risk of mortality or morbidity.
Family planning improves the health of women
and children by reducing the proportion of
pregnancies that are considered to be high risk.
Family planning also reduces the number of
women exposed to pregnancy-related health
risks, thus lowering the number of unintended
pregnancies and births.
The global community generally agrees that
family planning prevents maternal deaths by:
 Reducing the number of times a woman is
exposed to the risks of pregnancy30,31
 Helping women avoid unintended and closely
spaced pregnancies—a study in Bangladesh
found that very short pregnancy intervals are
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Family Planning and the SDGs
linked with 7 times increased risk of induced
abortion32
 Helping women avoid more than 4 births, or
births after 35 years of age30
The healthiest times for a pregnancy are
between the ages of 18 and 34 and at least
24 months after a birth (which ensures about
3 years between births), while avoiding more
than 4 births.
On newborn and child health, a wealth of
studies conducted in both rich and poor coun-
tries, using diverse data sets, have found that
spacing pregnancies at least 24 months after a
live birth (or about 3 years between births) is
associated with lower newborn, infant, and child
mortality.23,33,34,35 Other studies, focusing on
contraceptives, despite mixed results have con-
cluded that family planning helps women space
their births and ‘‘is protective against short
intervals.’’36 Current analyses indicate that spa-
cing births reduces the risk of death in infancy by
up to 10%, and for children under age 5 by
21%.16,31,35
Questions remain on family planning’s
effects on children after they are born. A recent
study among infants in Kenya found that a
preceding birth interval of less than 18 months
was associated with a twofold increase in
mortality risk (compared with a birth interval of
36 months), while succeeding intervals of less
than 20 months were associated with a 245%
increase in early childhood mortality, compared
with last births.20 In another study, children in
Afghanistan with a preceding birth interval
less than 18 months or greater than 60 months
had significantly higher risks of dying due
to diarrhea, sepsis, and low birth weight
than children with a preceding birth interval of
24–35 months.37 Finally, a systematic review
found evidence for folate depletion, vertical
transmission of infection, and transmission of
infectious disease between siblings as mechan-
isms that may explain the adverse perinatal,
infant, and child health outcomes associated with
short intervals.22
Questions also remain on the role of family
planning programs in child survival. A recent
analysis of trends in 57 countries (1985–2013) in
the modern contraceptive prevalence rate
(mCPR) and high-risk births found that the
countries with the fastest mCPR progress experi-
enced the greatest declines in high-risk births,
including those due to short birth intervals, high
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parity, and older-age births. The analysis found no
significant change in births to women younger
than 18 years of age, and it did not examine first
births. It also found that 63% of the increase in
the mCPR was due to family planning program
efforts, 21% due to economic development, and The healthiest
17% due to women’s education.38 times for a
Family planning helps women bear children pregnancy are
at the healthiest times of their lives—when they between the ages
are psychologically, physically, emotionally, and of 18 and 34 and
economically ready for a pregnancy and thus at least 24 months
most likely to survive, stay healthy, and have after a birth while
healthy children. Through strengthened, inte- avoiding more
grated service delivery and improved counseling than 4 births.
for women and girls, especially on the risks of
short birth intervals,39,40,41 high parity, and
advanced maternal-age pregnancies,42 family
planning should be playing a larger role in child
and maternal survival and in adolescent health
and well-being.
Family Planning Prevents HIV/AIDS Transmission
In an era when approximately 34 million adults Family planning
and children are living with HIV/AIDS, and has a critical role
women of childbearing age account for nearly to play in curbing
half of the infected population, family planning the HIV/AIDS
has a critical role to play in curbing the HIV/AIDS epidemic.
epidemic.
Correct and consistent use of male or female
condoms prevents transmission of the HIV virus.
It also prevents unintended pregnancy in women
with HIV, and thus potential transmission of the
virus to the newborn, as well as maternal deaths
(including those related to HIV). A modeling
study found that, in the 14 countries with the
largest numbers of pregnant women with HIV (at
the time of the study), programs to prevent
perinatal HIV transmission would prevent over
240,000 infant HIV infections if all women in
need used the most efficacious antiretroviral
regimen available; the estimated cost would be
over US$131 million, or US$543 per infant
infection averted per year. In comparison, the
annual cost of providing family planning to all
women with HIV who wished to prevent unin-
tended pregnancies was estimated at about
US$26 million in the 14 countries (US$33 million
globally). If all unmet needs for family planning
were satisfied for pregnant women with HIV,
423,000 births could be prevented at a cost of
US$61 per birth averted in the 14 countries.43
While approximately 1 in 4 women in sub-
Saharan Africa has an unmet need for family
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Family Planning and the SDGs
planning, studies have shown that women living
with HIV have higher unmet need for family
planning and reproductive health services than
the general population, in part due to lack of
investment in integrated family planning and
HIV services.44 For example, a 2012 study found
that programs that have ‘‘succeeded in promoting
condom use and providing HIV prevention and
treatment services y have largely missed the
opportunity to address the contraceptive needs of
the key populations they serve.’’44 Another recent
study found that if the needs of women with HIV
for modern contraceptive methods and antiretro-
viral medication were both fully met, HIV
transmission from mothers to newborns would
be nearly eliminated—reduced by 93% annually,5
greatly contributing to the ‘‘AIDS-Free Genera-
tion’’ goal of the U.S. President’s Emergency
Plan for AIDS Relief (PEPFAR). Pursuing oppor-
tunities to advance family planning integration
with HIV services would significantly expand
family planning access across Africa and address
unmet need.
Goal 4. Quality Education: Ensure Inclusive
and Equitable Quality Education and
Promote Lifelong Learning Opportunities
for All
Family Planning Supports Women’s and Girls’
Education
Family planning can help women and girls,
especially those who have become mothers, stay
in school, become literate, learn a trade, start a
business, or otherwise achieve their educational
Early and and employment goals. Early and unintended
unintended pregnancy can be both a cause and a consequence
pregnancy of dropping out of school.45
can be both Since 2000, adolescent pregnancy has declined
a cause and a only modestly in most countries,46 and adolescents
consequence of continue to face many barriers in obtaining
dropping out of contraceptive services and commodities.47 In
school. 2015, in 56 USAID-assisted countries, approxi-
mately 22 million adolescents ages 15–19 had
begun childbearing and, of these, 4.3 million have
had a second or third child.48 Adolescent preg-
nancy affects the adolescents themselves, their
families, communities, and broader society.18 With
such high numbers of adolescent pregnancies
globally, the world ‘‘squanders the well-being,
talents, and contributions’’ of the 20,000 young
girls under the age of 18 who give birth each
day.’’49
Research shows how family planning sup-
ports girls’ and women’s education:
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 An analysis in Iran explored married women’s
contraceptive use and education and found
that those using a modern contraceptive
method before the first birth were 84%
more likely to advance their education by
1 to 2 years than those not using any method
before the first birth.50
 An analysis of 200,000 married women from
242 districts in 26 African countries concluded
that the number of births to women with
children under age 6 and short intervals
between the last 2 children ‘‘have substantial
negative effects’’ on women’s employment
outside agriculture.’’51
 A series of case studies concluded that ‘‘over-
all well-being of women and girls improves as
fertility declines, especially as it relates to
their maternal health, educational attain-
ment, and workforce participation,’’ and
fertility decline has had a more positive
impact on girls’ education than it has had
on boys’ education.52
 A study in Bangladesh found wide-ranging
and multiple, positive impacts of family plan-
ning on the education and empowerment of
women and girls. Women in the family
planning-maternal and child health interven-
tion area had not only fewer children with
longer intervals between births but also higher
individual and household incomes than that of
the women and households in the comparison
group. The daughters of the program house-
holds were better educated than the daughters
of families who were not in the program.53
 The lifetime opportunity costs of adolescent
pregnancy—a measure of the annual income
adolescent mothers forgo over their lifetime—
range from 1% of annual gross domestic
product (GDP) in a large country, such as
China, to 30% of annual GDP in a smaller
economy such as Uganda. If adolescent girls in
Brazil and India were able to wait until their
early twenties to have children, the increased
economic productivity would equal more than
US$3.5 billion and US$7.7 billion, respectively.54
Goal 5. Gender Equality: Achieve Gender
Equality and Empower All Women and Girls
Family Planning Advances Gender Equality and
Empowerment
Gender equality and empowerment call for equal
access to resources, services, and opportunities.
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Family Planning and the SDGs
Gender equality refers to equal enjoyment of
human rights, goods, opportunities, and services
among women and men, while empowerment
refers to expanding people’s capacity to make and
act on decisions.55 They require addressing the
barriers women face in making decisions about
their own daily lives.46 Women’s access to their
chosen family planning method and their ability to
negotiate use of the method, therefore, strongly
supports gender equality and empowerment.
Many women, however, are unable to make
and act on decisions affecting their reproductive
lives. A 2014 report found that less than half of
currently married women use modern contra-
ception in 37 of 46 countries, and around one-
quarter or more of currently married women have
an unmet need for family planning in 21 of the
46 countries.46 High levels of unmet need may
indicate that women are not empowered to use
contraception because they lack access to health
care or are unable to negotiate family planning
with their partner. Increasing women’s ability to
choose the number, timing, and spacing of their
children, or their ability to decide if they want to
bear children at all, is fundamental for women’s
control over the circumstances of their lives and
for the full achievement of SDG 5.
While family planning programs are not the
only contributors to increasing equality, empow-
erment, and education, the evidence is clear that
family planning makes a critical contribution
toward achieving these global goals. These
broader societal impacts have been achieved, in
part, through well-designed and implemented
service delivery programs that reach underserved
communities—programs that should now be
scaled up across Africa and Asia.56,57,58,59,60
PLANET
In 2016, scientists issued an urgent environmen-
tal call—‘‘we have a global emergency’’61—and
predicted that climate change will be quicker and
more catastrophic than anticipated.62 They stated
that even 2 degrees Celsius63 of global warming
would be too much and recommended that
‘‘fossil fuel CO2 emissions should be reduced as
rapidly as practical.’’ While not all agree with the
scientists’ dire assessment, their pragmatic
recommendations are ones that all concerned
with planetary health should heed. Family plan-
ning has a critical role to play in the growing
social movement of support for the transforma-
tion from ‘‘public to planetary health.’’64
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Clear and compelling evidence points to Women’s access
serious consequences of rapid population growth to their chosen
on environmental outcomes. Population dynamics, family planning
including human population size, growth, den- method and their
sity, and migration, are important drivers of ability to
environmental and natural resource degradation, negotiate use of
including land, forests, biodiversity, and water.65 the method
The relationships are complex, mediated by strongly supports
poverty, technology, and management practices, gender equality
among other factors.66 However, as recognized in and
the 2013 Second International Population,
empowerment.
Health, and Environment Conference, ‘‘poor
reproductive health outcomes and population
growth exist hand-in-hand with poverty and
unsustainable natural resource use,’’ especially
in remote and rural communities.67 Although up-
to-date empirical data on the specific role of
family planning is scarce, a recent review of the
existing evidence found that integrating family
planning into non-health sector projects, such as
natural resource management, has led to
improvements in environmental indicators,
increased use of contraceptives, and, in instances
where long-term measurement was possible,
declines in parity or crude birth rates.67
Goal 6. Clean Water and Sanitation: Ensure
Availability and Sustainable Management
of Water and Sanitation for All
Family Planning Mitigates Population Growth’s
Effects on Access to Water and Sanitation
In 2014, the World Economic Forum identified
water crises as the global systemic risk of third
highest concern.68 Population growth affects
water scarcity in important ways. It contributes
to increased demand and competition for water
for domestic, industrial, and municipal uses,
including irrigation, and limits the amount of
water available per person. Estimates suggest
that by 2035, 3.6 billion people will be living in
areas of water stress or scarcity, up from
approximately 2 billion today.69
Population growth also negatively affects
access to sanitation. The United Nations Chil-
dren’s Fund (UNICEF) and the World Health
Organization (WHO) estimate that, in 2015,
some 2.4 billion people—over one-third of the
world’s population—lacked access to improved Family planning
sanitation.70 Between 1990 and 2011, Eastern has a critical role
and Southern Africa and West and Central to play in the
Africa experienced massive population growth, planetary health
and the number of people practicing open movement.
defecation in both regions rose to over
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Family Planning and the SDGs
100 million.70 In sub-Saharan Africa overall, the
number of people defecating in the open is still
increasing, largely due to population growth,
declared UNICEF and WHO.70
To what extent can family planning influence
availability of water and sanitation? While the
evidence is not extensive:
 Analyses have highlighted water availability
under projected scenarios of high and low
fertility. For example, estimates suggest that
in Jordan, with low fertility (total fertility rate
of 2.1 rather than the current rate of 3.8) 26%
less water (644 cubic meters versus 733 cubic
meters) would be required for the country as a
whole in 2040.71
 Analyses have also found that family plan-
ning programs in Egypt and Jordan have
generated modest sectoral savings in water
and sanitation (but significant sectoral sav-
ings in health and education).71,72
Goal 7. Affordable and Clean Energy:
Ensure Access to Affordable, Reliable,
Sustainable, and Modern Energy for All
Integrated Population, Health, and Environment
Projects Can Expand Access to Clean and Renew-
able Energy
Access to clean and renewable energy is a global
issue. Clean energy is defined as heat and
electricity produced from renewable sources
(wind, sun, rain, waves, tides), generating little
or no pollution or emissions. In contrast, approxi-
mately 2.8 billion people cook with firewood and
other fuels that are linked with health issues and
widespread deforestation.73 In 2012, at least
4.3 million premature deaths, mostly to women
and children, were attributed to household air
pollution and the effects of reliance on polluting
cook stoves.74
Over the years, population growth has eroded
renewable energy gains. A 2013 World Bank
Integrated report found that although 1.7 billion people
population, gained access to electricity in the last 10 years,
health, and ‘‘this is only slightly ahead of population growth
environment of 1.6 billion over the same period.’’73 Therefore,
projects have ‘‘the pace of expansion will have to double’’ to
successfully meet the 2030 targets for modern electricity
introduced both access.
family planning Integrated population, health, and environ-
and clean energy ment (PHE) projects have successfully introduced
into communities. both family planning and clean energy into
communities. A family planning project in
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Uganda collaborated with a clean energy provider
to provide solar lights to family planning peer
educators. Prior to the project, the peer discus-
sions were necessarily held during daylight hours
and thus engaged women only. The solar lights,
powered by the sun, were cleaner, more sustain-
able, and less expensive than kerosene, and they
enabled the peer educators to visit homes at
night—when the men would be home from
work—to talk to couples about family planning.75
Goal 9. Industry, Innovation, and
Infrastructure: Build Resilient Infrastructure,
Promote Inclusive and Sustainable
Industrialization, and Foster Innovation
Family Planning Contributes to Building Resilient
Infrastructures
Resilience refers to the ability of households,
communities, systems, and countries to respond
to and recover from shocks and stresses in ways
that reduce chronic vulnerability and facilitate
inclusive growth.76
The dramatic case of the Sahel demonstrates
the important role that family planning can play in
helping to create resilient countries and commu-
nities. Since 1960, the Sahel, ‘‘one of the most
chronically vulnerable regions of the world’’76
encompassing 10 countries and 100 million
inhabitants, has experienced severe drought, food
insecurity, low rainfall, environmental degradation,
and civil conflict, leading to declining agricultural
production. All countries in the Sahel have
experienced the ‘‘gendered nature of natural
disasters.’’77 Four of the 10 countries with the
highest total fertility rates in the world are in the
Sahel (Niger 7.6, Chad 6.5, Burkina Faso 6.0, and
Mali 5.9).76 Contraceptive use by married women
is extremely low—for example, less than 2% of
married women in Chad use contraception.
Continuing this trajectory of high fertility and
low contraceptive use will severely undermine
these countries’ abilities to respond to social
sector needs. In Niger, population growth is 4%
annually and will double in just 20 years. ‘‘This
growth will require a massive investment in
schools, health clinics, and job creation for
youth,’’ with additional investment also needed
in agriculture and livestock systems to ensure
food security. Increased investment in family
planning in the region could make a critical step
toward resilience.78
An analysis in Egypt helps us understand how
family planning and lower population growth
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Family Planning and the SDGs www.ghspjournal.org

helped build a more resilient infrastructure for

health and economic development. The Egyptian
family planning program contributed to a decline
in the total fertility rate, from 5.6 in 1976 to 3.1 in
2005. During this time, use of contraception
increased from 19% to 59%, made available
through the expansion of public-sector and NGO
clinics.72 Under conditions of constant fertility in
Egypt, by 2040 there would be 3.6 million births
per year. On the other hand, if the fertility rate
were lowered, by 2040 there would be about
2 million births per year (about 2.4 per woman).
Under this scenario, there would also be79:

 1.3 million fewer people entering the labor

force
 6.4 million fewer primary students in 2040
 80 billion Egyptian Pounds saved in health
care costs
 20% more land per person in 2040
 13% less water required
 17% more electricity available per person
Analysis revealed that, between 1980 and
2005, the family planning program contributed to
45,838 million Egyptian Pounds in savings in
expenditures on education, child health, and food
subsidies, while costing 2,402 million Egyptian
Pounds. The resulting lower health care and
education costs, and more land, water, electricity,
and jobs available per person, has yielded multi-
ple development benefits for Egypt and an
improved quality of life for Egyptians.72
Goal 11. Sustainable Cities and
Communities: Make Cities and Human
Settlements Inclusive, Safe, Resilient, and
Sustainable
Family Planning Contributes to Building Safe,
Resilient, and Sustainable Cities
Studies have found that it is ‘‘not only rapid
population growth, but rapid urbanization that is
causing problems for the poorest countries.’’80
Estimates indicate that the world is confronting
the largest wave of urbanization in human
history.81 By 2030, about 5 billion people will live
in cities,81 putting huge pressure on infrastructures,
such as health, water, sanitation, and education.
 The urban population in 2014 accounted for
54% of the total global population, up from
34% in 1960, and continues to grow.82
Houses in Cambodia stand on the Siem Reap River, which is clogged
with litter and refuse.
 Family planning
Africa is experiencing the most rapid urbaniza-
and lower
tion in the world, with annual urban growth
rates in recent years of 3.36% per year.83 As the
population
UN Economic Commission for Africa stated in
growth can help
a recent report, ‘‘Urbanization, together with
build a more
Africa’s approaching demographic transition,
resilient
may well become the most decisive determi-
infrastructure for
nants of Africa’s economic and social develop-
health and
ment since independence.’’83 economic
 The estimated number of slum dwellers is development.
increasing, from over 650 million in 1990 to
about 863 million in 2012.81 In Africa between
1990 and 2010, the proportion of urban residents
living in slums declined from 70% to 62%, ‘‘yet
the actual number of slum dwellers has almost
doubled from 103 million to 200 million.’’84
Urban growth in Africa is happening so quickly
that it is overwhelming governments’ abilities to
provide education, health services, housing, drink-
ing water, transportation, electricity, and waste
disposal.84 The latest Demographic and Health
Survey data show that although urban women in
Africa continue to have fewer children than their
rural counterparts,85 the urban total fertility rate is
still above 3 in most countries.85 While many
assume that urban dwellers have greater access to
family planning messages and services than rural
populations, in many instances this is not the
case.86
Findings from a longitudinal family planning
study in the urban areas of India (Uttar Pradesh),

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Family Planning and the SDGs
Kenya, Nigeria, and Senegal shed light on
effective, evidence-based strategies to address
the unmet need for family planning of urban
women and slum dwellers. The study found that
exposure to demand-generation activities was
significantly and positively associated with mod-
ern method use in all of the countries’ studied,
showing that ‘‘targeted, multi-level demand
generation activities can make an important
contribution to increasing modern method use
in urban areas of Africa.’’87
Goal 12. Responsible Consumption and
Production: Ensure Sustainable
Consumption and Production Patterns
Family Planning Can Help Reduce Population
Effects on Food and Chemical Waste
Population According to the United Nations Environment
dynamics have Programme, ‘‘The well-being of humanity, the
an important environment, and the functioning of the econ-
connection to both omy, ultimately depend upon the responsible
the challenges of management of the planet’s finite natural
and solutions to resources. These challenges are mounting as the
the problem of world population is forecast to reach over 9 billion
climate change. by 2050.’’88 Sustainable consumption and pro-
duction is about managing finite resources and
energy efficiency. Key SDG 12 targets involve
managing resources efficiently by reducing
waste—for example, by 2030, halving per capita
food waste, reducing waste generation, and
achieving sound management of chemical waste.
Countries of the Organisation for Economic
Co-operation and Development (OECD) produce
almost half of the world’s waste, while Africa and
South Asia produce the least. But the issue of
waste management is relevant for Asia and Africa
and for family planning because, as a World Bank
report observed, ‘‘y waste is inextricably linked
to urbanization.’’89 It noted, ‘‘Today, more than
50% of the world’s population lives in cities, and
the rate of urbanization is increasing quickly.’’ As
urbanization increases, income and consumption
also increase, leading to a corresponding increase
in waste. The report found89:
 Improving waste management in low-income
countries is an urgent priority.
 Poor waste management has an enormous
impact on health and well-being—contribut-
ing to flooding, pollution, respiratory ail-
ments, diarrhea, and dengue fever.
 Today there are about 3 billion urban resi-
dents generating about 1.2 kg of waste per
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person per day; by 2025, this will increase to
4.3 billion urban residents generating about
1.4 kg of waste per person per day.
 In lower-income cities, solid waste management
is usually the single largest budgetary item.
Given the urgency of these issues, studies are
needed on the role family planning could play as
it relates to urbanization and reduction of food
and chemical waste, and the sectoral financial
savings that might be generated as a result.
Goal 13. Climate Action: Take Urgent
Action to Combat Climate Change and Its
Impact
Family Planning Helps Address the Challenges of
Climate Change
Population dynamics have an important connec-
tion to both the challenges of and solutions to the
problem of climate change. Rapid population
growth exacerbates vulnerability to the negative
consequences of climate change and exposes
growing numbers of people to climate risk. The
Intergovernmental Panel on Climate Change
(IPCC) considers population (along with eco-
nomic growth and technical change) ‘‘one of the
root causes of greenhouse gas emissions.’’90
Meeting family planning needs will stem popula-
tion growth, easing challenges associated with
adapting to climate change impacts and reducing
the growth of greenhouse gas emissions.
 A 2015 study on family planning as a cost-
effective strategy to address food insecurity
and climate change concluded that slowing
population growth can ‘‘slow global climate
change, by providing 16% to 29% of the needed
emissions reductions’’ by 2050 and reduce the
need to increase food production.91,92 By the
end of the century, the effect of slower
population growth could reduce total emis-
sions from fossil fuel use by 37% to 41%.
 Another study found that improving access to
family planning is a relatively inexpensive
intervention for reducing carbon emissions
compared with other strategies such as solar,
wind, and nuclear power; biofuels; or carbon
capture and storage.93
 The IPCC argues that ‘‘providing access to
reproductive health services (including mod-
ern family planning)’’ is an opportunity ‘‘to
achieve co-benefits y to improve child and
maternal health through birth spacing and
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Family Planning and the SDGs
reduce population growth, energy use, and
consequent CAP [climate-altering pollutants]
emissions over time.’’94
 An analysis examining the relationship
between food security, population growth,
and climate change in Ethiopia showed the
potential of family planning to address the
food security gap resulting from decreased
crop productivity due to climate change.
Assuming the current pace of climate change
continues, the study found that, by the year
2050, slower population growth would ‘‘com-
pensate completely for the effects of climate
change on food insecurity.’’95
An analysis found that between 2004 and
2009, in government reports articulating priorities
for climate change adaptation, 37 of 40 govern-
ments recognized that population growth was
important for climate change, yet only 6 proposed
activities to address it.96 The analysis called for
broad-based adaptation of an integrated approach
and gave the example of an integrated watershed
management project in Ethiopia in Wichi province
that aimed to improve crop production, minimize
biodiversity loss, and increase access to family
planning and HIV/AIDS awareness. It concluded
that governments’ repeated emphasis on the
relevance of demographic trends in their climate
change adaptation plans ‘‘provide a strong collec-
tive case for the ‘mainstreaming’ of an integrated
approach y exemplified by the Ethiopian case
study.’’ Such a call is still highly relevant today.
Goal 14. Life Below Water: Conserve and
Sustainably Use the Oceans, Seas, and
Marine Resources for Sustainable
Development
Family Planning Helps to Protect Declining Marine
Resources
Under intense population pressure, global fish-
eries are disappearing and ocean resources are
becoming extinct.
 A 2009 study of global commercial fisheries
found that ‘‘80% of fish stocks have either
been fully exploited, overexploited, or have
collapsed.’’97 While reducing the catch by 20%
to 50% is needed for sustainable fishing,
demand for fish is expected to increase by
35 million tons due to increased consumption
and population.
 Of the 21 marine species known to have
become extinct in the past 300 years, 16
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disappeared since 1972.98 Population growth
affects the oceans in many ways including
coral reef damage; accidental killing of mil-
lions of tons of birds, fish, and sea turtles;
runoff laced with massive chemical fertilizer
applications creating ocean ‘‘dead zones;’’ and
a vast amount of discarded waste of 6.8 billion
consumers, which finds its way to the oceans.
 Population growth will likely impact the
success of programs meant to help species
rebound and protect the ocean ecosystem.
More research is needed on how family
planning can support the protection of oceans
and marine resources.
Goal 15. Life on Land: Protect, Restore, and
Promote Sustainable Use of Terrestrial
Ecosystems, Sustainably Manage Forests,
Combat Desertification, and Halt and
Reverse Land Degradation and Halt
Biodiversity Loss
Family Planning Helps Mitigate the Effects of
Deforestation and Unhealthy Interaction Among
Humans, Domestic Animals, and Wildlife
The world loses approximately 14.5 million
hectares of forest each year.99 As populations As populations
grow rapidly, the demand for food and forest grow rapidly, the
products also grows, and forest areas are turned demand for food
into fields for agriculture and commercial forestry. and forest
A comprehensive study of 46 countries in products also
Africa, Asia, and Latin America found that grows.
‘‘agriculture is the main driver of deforestation,
causing 73% of all deforestation.’’100 Deforesta-
tion threatens the well-being and livelihoods of
millions of people who heavily depend on forest
resources.101,102 Deforestation also contributes to
biodiversity loss: it is estimated that the South-
east Asia region, which has the highest relative
rates of deforestation, will lose three-quarters of
its original forests and up to 42% of its
biodiversity by 2100.103 Rapid population growth
is a driver of biodiversity loss.
Preventing desertification and land degrada-
tion is also part of these goals. Desertification
occurs with intensive farming, as well as chang-
ing climate conditions. Population density con-
tributes to soil depletion and erosion. Providing
men and women with family planning to achieve
their desires for smaller family sizes will con-
tribute to reduced rates of deforestation, deserti-
fication, and land degradation.
Population dynamics can also contribute to
unhealthy interactions among humans, domestic
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Family Planning and the SDGs
animals, and wildlife. Human population density
has been found to be a ‘‘significant independent
predictor’’ of emerging infectious diseases.104
Population expansion is linked to other under-
lying drivers of disease emergence, including
environmental changes. For example, increasing
interaction among humans, domestic animals,
and wildlife, following land use change, is
considered to be a significant contributor to
disease emergence.105
PROSPERITY
Goal 8. Decent Work and Economic
Growth: Promote Sustained, Inclusive, and
Sustainable Economic Growth, Full and
Productive Employment, and Decent Work
for All
Family Planning Contributes to Economic Growth
One important way that family planning con-
tributes to economic growth is by facilitating
changes in a country’s age structure. Rapid
fertility decline, which is linked to increased
family planning use, lowers the ratio of depen-
dents to income earners. This results in a higher
proportion of wage earners and leads to national
savings. With supportive socioeconomic policies
and attention to equity, countries can then
experience a ‘‘demographic dividend’’ of rapid
economic growth. Estimates indicate that the
demographic dividend effect of family planning is
most pronounced in countries with current high
fertility, where rates of return on economic
productivity and potential lifetime earnings from
improved availability and uptake of contraception
could exceed 8% of GDP by 2035.’’1
In the case of the East Asian Tigers (Hong
Kong, Singapore, South Korea, and Taiwan), the
demographic dividend lasted up to 25 years and
The poor-rich gap has been estimated to account for between 25%
in contraceptive to 40% of East Asia’s ‘‘economic miracle.’’106
use is diminishing, Across Africa, estimates suggest that a demo-
but gaps remain in graphic dividend could raise average incomes
many sub- by 56% compared with a scenario in which the
Saharan African share of the working age population remains
countries. constant.107 The demographic dividend is a
window of opportunity for countries to take
advantage of a robustly expanding workforce.
The payoffs will be high if social and economic
policies support the education and employment
of young people, especially girls.
South Korea and Thailand, demographic
dividend success stories, represent strong exam-
ples of countries’ aligning population policy and
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family planning services with human capital
development policies to accelerate economic
growth.108,109,110
PEACE
As a multi-sectoral intervention, family planning
also contributes to reaching vulnerable popula-
tions, mitigating conflict, and achieving state
stability and peace.
Goal 10. Reduced Inequalities: Reduce
Inequality Within and Among Countries
Family Planning Promotes Inclusive Societies by
Addressing the Needs of Disadvantaged Populations
SDG 10 states, ‘‘There is growing consensus that
economic growth is not sufficient to reduce
poverty if it is not inclusive. y To reduce
inequality, policies should be universal in princi-
ple paying attention to the needs of disadvan-
taged and marginalized populations.’’111
Unmet need for contraception is often highest
among the most disadvantaged and vulnerable—
adolescents, the poor, those living in rural areas
and urban slums, people living with HIV, and
internally displaced persons. These groups have
the fewest resources and are the least able to
deal with the demands of an unexpected preg-
nancy. Postpartum women have especially high
unmet need: 61% of women within 1 year of their
last birth have an unmet need for modern
contraceptive methods.112 Effective family plan-
ning programs reach these underserved popula-
tions and will need to accelerate efforts in this
area if the universal access goals of SDGs 3.7
(universal access to sexual and reproductive
health-care services), 5.6 (universal access to
sexual and reproductive health and reproductive
rights), and 10 (reduce inequality) are to be
achieved. A 2015 study showed that, overall, the
poor-rich gap in contraceptive use is diminishing,
and even more so when family planning pro-
grams are strong. Gaps remain in many sub-
Saharan African countries.113
At the individual and household level, experts
note that identifying the effect of demographic
factors on economic welfare has ‘‘proved elusive,’’
and finding the links between household poverty
and childbearing has ‘‘proved contentious.’’8
As discussed under the SDGs for poverty, educa-
tion, and equality, some studies show that more
women are likely to enter the labor force with
fewer children114; families who received family
planning and maternal-child health services were
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Family Planning and the SDGs
more likely to have higher incomes and greater
savings and assets53,115; and fewer children per
family leads to increased household savings and
increased investments in each child.116 A study
from Pakistan found that the direct effect of more
children of all age/sex combinations on savings is
negative and substantial,117 and a study from
Nigeria found that household size was linked
with the probability of being poor.118
These few studies suggest that new research
is needed on fertility’s effects on household
income and savings.
Goal 16. Peace, Justice, and Strong
Institutions: Promote Peaceful and Inclusive
Societies for Sustainable Development,
Provide Access to Justice for All, and Build
Effective, Accountable, and Inclusive
Institutions at All Levels
Family Planning Contributes to Peace and Stability
Studies have shown that a large ‘‘youth bulge’’
(defined as a high proportion of youth 15 to 29
years old relative to the older adult population) is
associated with a high risk of civil conflict.119
That is, states with youthful age structures—
especially within a politically organized minor-
ity120—are more likely to experience armed,
intrastate conflict and other types of violence.
The political impact of fertility decline is
significant. As a country and its population age,
studies show that the probability of attaining and
maintaining a liberal democracy is increased.121
Currently, more than 40 countries are
‘‘young,’’ with total fertility rates above 4 children
per woman. However, in another 70 countries the
demographic transition is more advanced, and
the chances for liberalization—and stability—are
greater.122
In many of the ‘‘young’’ countries, large
numbers of alienated youth cannot find jobs
and are easy recruits for radical groups that can
provide a regular salary. While family planning is
not the sole solution, it is important to under-
stand that the high proportion of jobless youth
relates to the overall population structure and the
sluggish economies that cannot support even
menial jobs for everyone. Other experts also see
the ‘‘youth bulge’’ as a possible precursor to
violence. They urge such countries to consider
increasing support for girls’ education, family
planning, and youth employment, contending
that ‘‘the pill is mightier than the sword.’’123
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With the help of an NGO in Alirajpur district, India, a father started
a basket-weaving business, allowing him to send his girl child to
school.
PARTNERSHIP
Goal 17. Partnerships for the Goals:
Strengthen the Means of Implementation
and Revitalize the Global Partnership for
Sustainable Development
Family Planning Partnerships Can Support the
Achievement of the SDGs
A revitalized family planning agenda continues to
be needed.8 Family planning services still fall For every US$1
short of need in all developing regions, though invested in family
analyses show that for every dollar invested in planning, up to
family planning, between US$1.47 and US$4.00 US$4 is saved in
is saved in maternal and newborn health maternal and
care.5,124 Investing in family planning, in addition newborn health
to maternal and newborn services, can save care.
US$1.5 billion while achieving the same health
outcomes.5 According to the new Global Invest-
ment Framework for Women’s and Children’s
Health, scaling up access to and use of modern
contraceptive methods would directly avert 53%
(78 million) of the 147 million child deaths
prevented under the high-investment scenario
but would require only 4% of intervention-
specific costs between 2015 and 2035.1
A wide range of global partnerships have
made important strides in recent years in
promoting and strengthening family planning.
These partnerships—including FP2020, the
UN Commission on Life-Saving Commodities,
the Ouagadougou Partnership, and the MDG
Health Alliance—provide a foundation and a
203
Family Planning and the SDGs www.ghspjournal.org

BOX. The Central Role of Family Planning in Achieving the Sustainable Development Goals Across the
5 Themes of People, Planet, Prosperity, Peace, and Partnership

PEOPLE

 Family planning advances human rights.

 Family planning helps reduce poverty.
 Family planning contributes to improved nutrition outcomes.
 Family planning saves lives.
 Family planning prevents HIV/AIDS transmission.
 Family planning supports women’s and girls’ education.
 Family planning advances gender equality and empowerment.

PLANET

 Family planning mitigates population growth’s effects on access to water and sanitation.
 Integrated population, health, and environment projects can expand access to clean and renewable energy.
 Family planning contributes to building resilient infrastructures.
 Family planning contributes to building safe, resilient, sustainable cities.
 Family planning helps reduce population effects on food and chemical waste.
 Family planning helps address the challenges of climate change.
 Family planning helps to protect declining marine resources.
 Family planning helps mitigate the effects of deforestation and unhealthy interaction among humans, domestic
animals, and wildlife.

PROSPERITY

 Family planning contributes to economic growth.

PEACE

 Family planning promotes inclusive societies by addressing the needs of disadvantaged populations.
 Family planning contributes to peace and stability.

PARTNERSHIP

 Family planning partnerships can support the achievement of the SDGs.

Global Health: Science and Practice 2016 | Volume 4 | Number 2 204

Family Planning and the SDGs
model for the collaborative, multi-sectoral efforts
that are needed to support sustainable develop-
ment. Moreover, these partnerships will be
critical in supporting country-level partnerships
that include the public and private commercial
sectors, foundations, civil society organizations,
and non-health sector groups (e.g., in education,
environment, income generation) to accelerate
country-level change in the years ahead, and to
ultimately achieve the Sustainable Development
Goals.
CONCLUSION: INVEST IN FAMILY
PLANNING TO ACHIEVE THE SDGS
In the time frame of the SDGs, the world has the
opportunity to achieve a grand convergence
between the developed and developing world,
ending preventable child and maternal deaths
and achieving relative parity in meeting the
family planning needs of women, men, couples,
and adolescents who want to space or limit
childbearing.
Family planning can accelerate progress across
the 5 SDG themes of People, Planet, Prosperity,
Peace, and Partnership and is critical to achieving
the goals and the post-2015 development agenda
(see Box for a summary). Empowering women to
choose the number, timing, and spacing of their
pregnancies is not only a matter of health and
human rights but also touches on many multi-
sectoral determinants vital to sustainable develop-
ment, including women’s education and status in
society. Without universal access to family plan-
ning and reproductive health, the impact and
effectiveness of other interventions will be less,
will cost more, and will take longer to achieve.
Global strategies and partnerships—and health
decision makers at all levels—must leverage the
abundance of available research, evidence, and the
range of justifications presented here to prioritize
family planning as a foundational component of
health, rights, and long-term development
strategies.
Acknowledgments: The opinions expressed herein are those of the
authors and do not necessarily reflect the views of the U.S. Agency for
International Development.
Competing Interests: None declared.
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Family Planning and the SDGs www.ghspjournal.org

Peer Reviewed

Received: 2015 Nov 18; Accepted: 2016 May 2; First Published Online: 2016 Jun 9

Cite this article: Starbird E, Norton M, Marcus R. Investing in family planning: key to achieving the sustainable development goals. Glob Health Sci
Pract. 2016;4(2):191–210. http://dx.doi.org/10.9745/GHSP-D-15-00374

& Starbird et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit
http://creativecommons.org/licenses/by/3.0/. When linking to this article, please use the following permanent link: http://dx.doi.org/
10.9745/GHSP-D-15-00374

Global Health: Science and Practice 2016 | Volume 4 | Number 2 210